Provider Demographics
NPI:1497771901
Name:SPORT CLINIC INC
Entity Type:Organization
Organization Name:SPORT CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT SERCETARY
Authorized Official - Prefix:
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:LANCE
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:510-438-0294
Mailing Address - Street 1:39180 FARWELL DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1052
Mailing Address - Country:US
Mailing Address - Phone:510-438-0294
Mailing Address - Fax:510-438-0468
Practice Address - Street 1:39180 FARWELL DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1052
Practice Address - Country:US
Practice Address - Phone:510-438-0294
Practice Address - Fax:510-438-0468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT18871225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03200ZMedicare PIN